Letters, April 2011

Smoking in mental health – time to quit taking it for granted
Why is it that smoking in mental health settings is still taken for granted, and that smokers with mental health problems are rarely offered comprehensive support to address their tobacco dependence? Contrary to common perception, mental health patients' motivation to quit can rival that of the general population, and they can give up smoking successfully when given appropriately tailored support (Banham & Gilbody, 2010; Siru et al., 2009). Given the high rates of smoking in this population and the resulting levels of smoking-related illness and premature death (Brown et al., 2000; Joukamaa et al., 2011) – with smoking being a major contributor to the immense health inequalities present in this group – one would naturally expect tobacco dependence treatment to be part of the standard care package for patients (West et al., 2000). However, even since the implementation of the smoke-free policy, there is very little evidence of comprehensive smoking cessation support for patients in NHS acute or community settings (McNally et al., 2006; Ratschen et al., 2009).

A pilot project aiming to implement a comprehensive tobacco dependence support and treatment service on inpatient wards and in the community, funded by the Department of Health as part of a bigger programme addressing smoking-related health inequalities, is currently carried out at the University of Nottingham. At the start of the project, we found that the treatment of tobacco dependence received very little (if any) attention in the settings covered. Hardly any standard instruments or procedures were applied to ensure that addressing smoking was part of the care pathway, and essential resources, such as protected staff time and routine stocking of nicotine replacement therapy, were missing. Additionally, common staff attitudes such as 'they can't quit,' 'smoking is all they have got' and 'it's not a good time for them to stop', combined with using cigarettes as an engagement tool, often meant that patients were not receiving comprehensive education and advice to enable them to make an informed choice about smoking.

Although it is early days, we feel the project has already made an impact. We have found that when given sufficient information on smoking, patients often make the choice to address their smoking. Our two smoking cessation advisers have experienced great interest in their service and successfully helped an encouraging number of patients to reduce (in a structured way with clear goals) and quit smoking in both acute and community settings. This, along with information sessions for staff (some of whom have also quit successfully) on the links between mental health and smoking has fired up support from staff for our project, which has in turn had a positive impact on patients. We are really encouraged by our success so far and, supported by the mental health trust, we are working hard to make the service even more accessible and tailored to the needs of mental health clients, and to get clinicians on board. If we continue to make an impact, then we hope the initiative may last beyond the end of this nine-month project.

Our success to date highlights the question: Given that quitting is arguably the single best thing someone can do to improve their quality of life, why are mental health patients not given the opportunity of support to achieve this? Tobacco dependence and mental health/illness are intricately interwoven and we believe that tobacco dependence treatment should be given as much consideration as treatment for mental health problems. Could and should psychologists, with their expertise in behavioural support and mental health, begin to systematically challenge smoking in mental health and thus help to halt the increasing health inequalities their clients are facing?

Camilla Parker
Elena Ratschen
University of Nottingham

References
Banham, L. & Gilbody, S. (2010). Smoking cessation in severe mental illness: What works. Addiction, 105(7), 1176–1189.
Siru, R., Hulse, G.K. & Tait, R.J. (2009). Assessing motivation to quit smoking in people with mental illness: A review. Addiction, 104(5), 719–733.
Brown, S., Barraclough, B. & Inskip, H. (2000). Causes of the excess mortality of schizophrenia. British Journal of Psychiatry, 177(3), 212–217.
Joukamaa, M., Heliovaava, M., Knekt, P. et al. (2011). Mental disorders and cause-specific mortality. British Journal of Psychiatry, 179, 498–502.
West, R., McNeill, A. & Raw, M. (2000). Smoking cessation guidelines for health professionals: An update. Thorax, 55(12), 987–999.
McNally, L., Oyefeso, A., Annan, J. et al. (2006). A survey of staff attitudes to smoking-related policy and intervention in psychiatric and general health care settings. Journal of Public Health, 28(3), 192–196.
Ratschen, E., Britton, J., Doody, G. & McNeill, A. (2009). Smoke-free mental health units: Avoiding the pitfalls. General Hospital Psychiatry, 31, 131–136.

Ethics and sexual orientation
We are responding to Josh Schwieso's response (February 2011) to Sylvia Kapp's letter '"Treating" homosexuality is unethical' (December 2010). Dr Schwieso's position that the moral majority should determine what forms of sexual identity, behaviour and desire are deviant, pathological and warranting of correction is deeply disturbing.

Firstly, Dr Schwieso misquotes Ms Kapp as contrasting the broad spectrum of human sexual behaviour (including homosexuality) with that which is deviant and pathological; he misses the critical statement from Ms Kapp that homosexual identity and behaviour 'is, in itself, not problematic'. Clearly, there are behaviours, such as sexual violence, which are covered by the criminal law and occur in both heterosexual and homosexual contexts, but these are problematic because of the nature of the act rather than the sexual orientation involved. Further, Dr Schwieso conflates and confuses the terms ethical, criminal, deviant and pathological and argues that 'what is accepted as appropriate and desirable in society is measured against ethical norms'. However, rather than advancing any ethical principles to measure behaviour against, he refers instead to 'widespread criminal and pathological behaviours that most people [our emphasis] would see as needing some form of treatment'.

Secondly, Dr Schwieso argues that evidence that a treatment is ineffective does not mean that effective treatments should not be pursued. He compares homosexual desire with 'serious personality disorders' which are also 'resistant to cure'. Clearly, the wish to continue to search for an effective 'cure' for homosexual desire only makes sense in an internal world where such desire is seen as pathological.

Thirdly, he accuses Ms Kapp of focusing 'only on those forms [of non-heterosexual sexuality] approved by liberal societies'. We can see no references in Ms Kapp's letter to specific sexualities or behaviours and we are left to wonder what the forms of sexual desire or behaviour are that Dr Schwieso sees as exclusively homosexual and which cannot be characterised 'as anything other than deviant'.

The reasons for rejecting the practice of 'treating' homosexual desire and identity are clearly laid out in Ms  Kapp's letter and are supported by the APA, the RCP and the BPS. The BPS Code of Ethics and Conduct (2009) states: 'Psychologists should respect individual, cultural and role differences, including (but not exclusively) those involving… sexual orientation.' The Professional Practice Guidelines for the BPS Division of Counselling Psychology (of which three of us are members) state: 'Practitioners will challenge the views of people who pathologise on the basis of such aspects as sexual orientation.'

We believe that the values and principles of respect, which are integral to our profession as psychologists, should extend to a celebration of the diverse forms of human experience, behaviour and identity and that any professional practice should be built on the goal of supporting each of us in achieving a positive identity and in being able to celebrate our differences as well as our similarities.

John Waite
Victoria Clarke
Andy Halewood
Naomi Moller
Department of Psychology
University of the West of England
Bristol

Persistence of neuromyths
Paul A. Howard-Jones's article ('From bran scan to lesson plan,' February 2011) provides an inspirational model for using neuroscience to develop teaching methods in school. However, as an educational psychologist I share the concerns expressed in the article about widely accepted 'neuromyths' within education and elaborated in Marc Smith's letter (March 2011). Marc Smith wonders 'why this kind of misinformation persists despite research to the contrary'.

I can start to answer this from my early experience as an educational psychologist. I picked up a range of neuromyths, including teaching to match learning styles and brain gym to integrate left–right hemispheric functions, from experienced educational psychologists and community paediatricians. Although not included in my training, I initially assumed them to be evidence-based, until I was asked by a teacher whether I would recommend brain gym. I tried to find some research to back up a recommendation and could find none. It was a salutary experience.

Marc Smith also asks how we as a Society might start to address misconceptions. From my own experience, I would suggest starting with initial training courses for psychologists so that they are fully prepared to tackle the misconceptions they will soon encounter. Another place to focus is the teaching of psychology in schools. Whereas subjects taught as part of the main curriculum are carefully designed to engage students in critical thinking, psychology – in the guise of study skills or social/emotional skills – can slip things in as 'fact' rather than scientific claims to be interrogated. Perhaps this is an area where the Division for Teachers and Researchers can raise awareness of issues, along with the Division for Child and Educational Psychology, and new generations of students could be equipped to critically evaluate psychological claims made in all spheres of life.

Rachel Ingram
Wray, Lancashire

Is IAPT the only political option?
Recent concerns about the sustainability of the Improving Access to Psychological Therapies (IAPT) initiative, in a context of dramatically imposed fiscal savings, provides us with the opportunity to have a hard look at the rationale for psychological interventions. We are of the view that the model enthusiastically embraced in the UK and now being adopted in Australia reflects a medical, not psychological, approach to common human unhappiness.

The prevailing design of services centres around the notion of delivering the optimal 'dose of treatment' to those people whose symptom scores are outside the normal range on standardised tests. Self-referrals to services are relatively uncommon. Those who miss appointments are followed up with letters reminding them of their missed appointment and admonishing them that they may be discharged from the service. People who stop attending before the clinician thinks treatment has ended are described as treatment 'drop-outs'. Those who do not fully embrace the activities the clinician presents to them are described as 'non-compliant', 'difficult to engage', 'treatment resistant' or 'lacking insight'. These practices exist despite the fact that recognising people's right to self-determination (including their right to withdraw from the receipt of services) is one of the core ethical values of the British Psychological Society (BPS, 2009).

These observations point up a medicalised approach to conceptualisation and intervention whereby, unquestioningly, unhappy people are turned into patients (Dowrick, 2008). But supposing that not everyone with 'presenting symptoms of anxiety or depression' is 'wasting their lives' (London School of Economics, 2006): what if they are experiencing a normal and intelligible variation on experience (human suffering)? Our suffering can be endured or comforted but it is not self-evidently a 'mental illness' to be 'cured', this time by conversational rather than chemical 'treatments'. Moreover, an original premise of the IAPT treatment ideology was that if we are able to 'cure' 'mental illness' then its 'sufferers' will return to work and incapacity benefits expenditure will be reduced. What if it is the oppressive work setting that needs fixing and not the individual? This is akin to treating shellshock in the First World War, with the hope of sending people back to the violent setting of their experience.

And does the economic rationale of this medicalisation even make sense? Based on the evidence that about one in five or six people report symptoms of a common mental disorder in a 12-month period (London School of Economics, 2006) and less than half of those people access professional services for these problems, we have invested a large amount of public funds in increasing the services available. However, only a proportion of those people experiencing symptoms of a mental health disorder express a perceived need for treatment. In an Australian survey conducted in 2007 about 20 per cent of respondents reported experiencing symptoms of a mental disorder (Meadows & Burgess, 2009) and approximately 65 per cent of those people did not access any services. However, those who reported symptoms and had a perceived need for treatment and were not accessing services made up only 2 per cent of the sample. Whether we set our target on 65 per cent or 2 per cent of those people reporting symptoms of a mental disorder has enormous implications for public spending, especially as the cut off between normal unhappiness and a professionally codified disorder is not easy to make in the general population (Wakefield & Schmitz, 2011).

Perhaps a truly biopsychosocial approach is now warranted, rather than the type of model described above with its medicalised character (Pilgrim, 2002). A proper adoption of this would pay close attention to the individual and their interactions in the social contexts that they occupy. We would prioritise the agency of individuals and would recognise the fundamental importance of people being able to control what is important to them (Mansell & Carey, 2009). Moreover, we would not presume that the technological fix assumed in the IAPT approach to mental health policy is the only option for society. Unhappiness happens to us all, to varying degrees, during our lives for a large variety of reasons: being 'treated' for it is only one of many political and ethical scenarios.

Timothy A. Carey
Centre for Remote Health and Central Australian Mental Health Service
David Pilgrim
University of Central Lancashire

References
British Psychological Society (2009). Code of ethics and conduct. Leicester: Author.
Dowrick, C. (2004). Beyond depression: A new approach to understanding and management. Oxford: Oxford University Press.
London School of Economics (2006). The depression report: A new deal for depression and anxiety disorders. London: LSE Mental Health Policy Group.
Mansell, W. & Carey, T.A. (2009). A century of psychology and psychotherapy: Is an understanding of 'control' the missing link between theory, research and practice? Psychology and Psychotherapy: Theory, Research and Practice, 82, 337–353.
Meadows, G.N. & Burgess, P.M. (2009). Perceived need for mental health care: Findings from the 2007 Australian Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry, 43, 624–634.
Pilgrim, D. (2002). The biopsychosocial model in Anglo-American psychiatry: Past, present and future? Journal of Mental Health, 11, 585–594.
Wakefield, J.C. & Schmitz, M.F. (2011). The challenge of measurement of mental disorders in community surveys. In D. Pilgrim, A. Rogers, and B. Pescosolido (Eds.) The SAGE handbook of mental health and illness. London: Sage.

High time for men?
With strange logic, Peter Branney and Brett Smith argue against the establishment of a 'Male Gender Section' because it would supposedly continue an entrenched idea that there are 'simply two sexes' (Letters, March 2011). In that case the Psychology of Women Section should be discontinued as well.
On the BPS website the Psychology of Women Section there are the following stated aims: 'Bring together everyone with an interest in the Psychology of Women; Provide a forum for the Psychology of Women in research, teaching, and professional practice; Increase awareness and action around gender and inequality issues within the British Psychological Society, Psychology profession, and the teaching of Psychology'.
There is no reason there should not be a Section with similar aims, focusing upon men rather than women.
Indeed, either there should be both Sections or there should be neither. If there is just one, how is this not discriminatory and sexist? It also needs to be pointed out that there are 11,508 men and 35,741 women who currently have BPS membership, very far from equal numbers. Moreover, university entry generally, but especially in psychology, is now increasingly dominated by young women, and boys lag behind girls in exam results in school. How are these facts not the result of anti-male sexism, at the very least in institutionalised form within the educational system in Britain?
It seems high time there was a Psychology of Men Section, to 'increase awareness of and action around gender and inequality issues'.

Ian Wray
Sheffield

The interesting debate over the need for a Psychology of Men Section continues. Most recently, Peter Branney and Brett Smith question this need on the basis that a male section would entrench dualism with respect to constructed gender categories of 'male' and 'female'. I was very happy to see such theories discussed within the pages of the psychologist as they are not widely understood and offer important insights into the fluidity of 'gender'. However, I felt that their argument actually strengthened the case for a Psychology of Men Section, as opposed to their view, that such a Section would reinforce dogmatic assumptions.

They suggest an online forum for the topic, but I would like to know what they would call this and whether it would be possible to avoid reference to men? I would also be interested in their opinion on the existence of a Psychology of Women Section. Like Peter Branney and Brett Smith, I am of the view that we exist in a society with entrenched and unhelpful views of gender but, without a Psychology of Men Section, how can we address issues such as the significantly higher suicide rate in men, the lower life expectancy and the higher rates of drug abuse and likelihood of imprisonment? Male terminology for such a section is not ideal, but it would offer a starting point and the space to address many issues, including those expressed by Peter Branney and Brett Smith.

Tom Grange
The Northgate Clinic, Edgware Community Hospital

Forces children: both seen and heard
Lynne Hipkin expressed her interest in hearing from 'any psychologists currently working with forces families' (Letters, January 2011).

Contrary to the assertion that the Ministry of Defence (MoD) does not acknowledge that service children may need support, we can assure her that this is, of course, recognised by the MoD. The MoD employs clinical, occupational and other applied psychologists, whose jobs involve psychological research, professional advice, policy development, and treatment of serving personnel and their families.

For centuries, the military has understood that fighting power is influenced by the well-being of the immediate family of service personnel. Indeed, current Army Welfare Policy states: 'The British Army recognizes that supporting soldiers' families contributes directly to a soldier's operational effectiveness. The British Army is therefore committed to ensuring that all Army families are provided with additional support, both during their soldier's deployment and in the event of a family emergency.' The importance of the family is not simply an Army issue. Tri Service policy acknowledges the central role of the family too: 'The critical connection between welfare and operational effectiveness affirms that the support provided for Service personnel and their family is "core" Armed Forces business.' Furthermore, the MoD has a Director Children and Young People, whose team's function is to provide support and promote the well-being of service children.
As the military acknowledge that family welfare is core business it is not surprising to learn that military psychologists, from different disciplines, conduct a considerable amount of work involving families. In addition, the MoD commissions work from independent psychologists and collaborates with others in the UK and overseas, consequently the MoD has access to a huge body of research in support of service families.
The psychological research underpinning MoD support for families is varied. For example each service conducts Service Families Attitude surveys (developed and analysed by psychologists) so that the views of spouses can be heard and family policy can be evidence-based. Recent work commissioned by the MoD, conducted by Haldane-Spearman Consortium psychologists, includes: work on the impact of separation on serving personnel, which identifies the impact on children and suggests measures that the MoD should make to improve their well-being; a study into the provision of welfare support to families during separation, comparing the MoD with other employers of personnel deployed overseas; and a literature review of support to parents with young families.

In addition, the King's Centre for Military Health Research (KCMHR) has conducted a number of studies, funded by the MoD, looking at communication with service families, the impact of the deployments to Iraq on service families and negotiating work–life balances in the armed forces. Currently, KCMHR is engaged in a major study on the impact of children of having a father in the military. The study will help policy makers provide better for the needs of children of military personnel.

Military psychologists work routinely to provide advice to service personnel who deal with support to service families during bereavement; military welfare organisations; chaplains; and teachers at schools that educate service children. In British Forces Germany (BFG) educational psychologists and social workers work directly with children and families and work closely with BFG Health and Psychiatric services which includes clinical psychology. In the UK, MoD social workers provide support to the families of patients and work closely with all military mental health professionals, including clinical psychologists, in care planning and with the delivery of mental health services.

Finally, it should be noted that research involving service children as participants requires ethical approval and an independent MoD Research Ethics Committee scrutinises research protocols.

We trust that this reply has reassured readers of The Psychologist that the MoD does understand that 'a serving soldier's family is perhaps the most valuable resource in terms of his or her well-being' and that we consider that this is 'significantly recognised in terms of psychological research'.

G.J. Walker-Smith
Head of Profession for Occupational Psychology
J.G.H. Hacker Hughes
Head of Profession for Clinical Psychology
MoD

Normal reporting
I read with interest the letter by Alexis Makin ('Deadly normalisation?', March 2011). Makin responds to a 'Media' page I had written, on behalf of the BPS Media and Press Committee, about a seminar on improving the mental health among UK military personnel. Makin raised the idea that this 'Media' page, in addition to an advert for the Royal Navy that appeared in the same edition, may have inadvertently contributed to the normalisation of state violence.

I would like to pick up on Makin's comments about the necessity of speaking out against institutions that may be seen as morally responsible for the suffering of military personnel. Such political comments are beyond the usual scope of the media page; its job is simply to report on psychological topics that have attracted some degree of media attention or are to do with the promotion of psychology as a discipline. The goal is not to discuss political issues such as the legitimacy of foreign conflicts. This is not to say that political issues are not important, but that there are other forums in which to discuss them.

Makin's own letter demonstrates apparently strong personal opinions against the idea of foreign conflict (e.g. referring to 'imperial violence in Afghanistan') and the need for psychologists to speak out against this (e.g. by following a more 'preventative approach'). I applaud the strength of these convictions and I believe that psychology does indeed have a role to play in politics (such as the APA's comments about torture: tinyurl.com/4tke96q) but a 'Media' page reporting on an event designed to help UK service personnel is not the place.

Mark Sergeant
BPS Media and Press Committee

Obituaries 

Fay Fransella (1925–2011)
Professor Fay Fransella, who has died aged 85, was a passionate advocate of personal construct psychology (PCP). Indeed, she considered that her life was transformed when, while working on her PhD at the Institute of Psychiatry, she came across the writings of the originator of this approach, George Kelly. At the time, she considered that she was in a 'psychological desert', but found in Kelly's theory a psychology that, unlike those to which she had been exposed, did not treat people as objects but rather as inquiring men and women, who need not be victims of their biographies. Fay's whole life exemplified the exploration of alternative constructions of the world, and the capacity thereby to reinvent oneself, that is central to PCP. She was born in Jersey, but her childhood was disrupted by the death of her mother when Fay was six years old, and the family's evacuation prior to the German invasion. After leaving school before the sixth form, she trained as an occupational therapist, obtaining her first job at Horton Hospital in Epsom, where by the age of 30 she was head of the largest occupational therapy department in the country. She was nevertheless dissatisfied, and took evening classes to obtain the O- and A-levels necessary for acceptance on a psychology degree. She completed this degree at University College London and then trained in clinical psychology at the Institute of Psychiatry, remaining as a lecturer.

During this period, she met Don Bannister, with whom she introduced PCP to a whole generation of psychologists by lectures and inspiring books such as Inquiring Man and A Manual for Repertory Grid Technique.

Fay, Don, and others formed the 'Kelly Club', and in 1964 she met Kelly for the first time when he visited Brunel University. She was later instrumental in organising the Second International Congress on Personal Construct Psychology (having decided that the 1975 Nebraska Symposium on Motivation, focusing on personal construct psychology, should be designated the first such congress), an event that has continued biennially ever since. In her opening address to the Congress, she made no secret of her ambitions, asserting that 'We are making a take-over bid for the discipline of psychology' and that (at the time of the 'cognitive revolution') 'If behaviour therapy is up for grabs – we must be in there doing the grabbing!'
In 1971 Fay was appointed Senior Lecturer, and subsequently Reader, in Clinical Psychology at the Royal Free Hospital School of Medicine, University of London. On retirement, she set up the Centre for Personal Construct Psychology. She was a founder member of the UK Council for Psychotherapy, and offered the first UKCP-accredited training courses in personal construct psychotherapy, as well as a 'diagnostic research' approach to organisations. It was later transferred to the University of Hertfordshire, where Fay was awarded a Visiting Professorship. She generously contributed to the university's Doctorate in Clinical Psychology until well into her eighties.

Fay's achievements were recognised by the British Psychological Society with the award of a Fellowship and by her being one of 12 psychologists invited to provide reminiscences in a book marking the Society's centenary. Her chapter in this book is but one of over 100 publications. She is perhaps best known for her research demonstrating that stuttering is the stutterer's 'way of life', whereas fluency is relatively meaningless. Her PCP analysis of, and therapeutic approach for, this condition has a much broader applicability. Indeed, it is clear that for Fay PCP was her 'way of life'. She is survived by Roy Hodson, whom she married in 1968.

David Winter
University of Hertfordshire